Complaint No.231 of 2022.

       Date of Institution:11.11.2022.

               Date of order:12.10.2023.

Suresh Kumar Son of Sh.Chuni Lal, resident of 100/6, Dala Farm, Jail Road Gurdaspur.

…...Complainant.

                                                         VERSUS

1.       Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), Regd. Office at 5th Floor, Chawla House, Nehru Place, New Delhi-110019 through its Regional Manager/Authorized Signatory.

2.       Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited), Service Branch CHIL, 15th Floor, Taneja Tower, SCO No.28, Distt Shopping Complex, Ranjit Avenue Amritsar, Punjab-143001, through its Branch Manager.

                                                                                                         ….Respondents.

                Complaint u/s 35 of The Consumer Protection Act.

Present: For the complainant: Sh.R.K.Nadala, Advocate.

    For the opposite parties: Sh.Sandep Ohri, Advocate.  

Quorum: Sh.Lalit Mohan Dogra, President, Sh.Bhagwan Singh Matharu, Member.  

ORDER

Lalit Mohan Dogra, President.  

          Complainant Suresh Kumar had filed the present complaint U/s 35 of the Consumer Protection Act against the opposite parties and praying that the directions may kindly be issued to the opposite parties to release the amount of medical claim i.e. Rs.7,51,388/-  alongwith interest @ 18% P.A. from the date of due till its realization alongwith compensation amount of Rs.1,00,000/- for causing mental and physical harassment including Rs.50,000/- as litigation expenses. Complainant has further prayed for directions to the opposite parties to revive his medical policy and for granting relief as this Hon'ble Forum/Commission may deemed fit, in the interest of justice.

2.       The case of the complainant in brief is that the official/agent of the opposite parties met with him and allured him about their medical policies and on their allurement he obtained policy No.30013982, Plan:- CARE, Cover Type:- Floater, Policy period start date 00.00 hrs 05.02.2021 till midnight 04.02.2023 and paid Rs.44,568/- as single mode premium and his wife namely Reena is the nominee of the policy in which cashless facility was provided to him. It was pleaded that at the time obtaining the policy, complainant and his wife have no previous medical history even they were duly checked up by the empanelled doctors and it was clearly mentioned in the policy cover note that complainant and his wife have no pre-existing disease. It was further pleaded that on 19.09.2021 complainant was got admitted in the Fortis Hospital, Amritsar for his medical treatment and discharged on 25.09.2021 and information in this regard was sent to the opposite parties and opposite parties sanctioned the medical claim of this period amounting to Rs.1,42,031/- whereas medical claim raised by the complainant was of Rs.1,57,000/- as per bills of the hospital. Complainant alleged that at the time discharge from the hospital an objection was raised by the opposite parties before releasing the medical claim vide their deficiency letter No.80578659-01 dated 25.09.2021 that "1. Exact Duration and Past History of Present Ailment with Ist consultation paper and all past treatment record, (CKD-Chronic Kidney disease) 2. Recent Passport Size Photograph of proposer/Nominee" and thereafter TPA (Third Party Administrator) of Fortis Hospital sent the requisite information to the opposite parties and they approved the medical claim No.80578659 of the complainant vide their letter dated 25.09.2021 and out of the total amount of Rs.1,57,000/- an amount of Rs.1,42,031/- was approved by them. It is further pleaded that on 08.10.2021 complainant got admitted at Max Saket, New Delhi due to disease (Right FTP Subacute On Chronic SDH Status Post Right FTP Minicraniotomy) and remained admitted till 15.10.2021 in this hospital and during this period complainant paid an amount of Rs.7,51,388/- and prior information was duly made to the opposite parties in this regard who at the time of admission sanctioned the pre-authorization amount of Rs.4,87,969/- to the hospital authorities but at the time of discharge opposite parties totally denied to pay the pre-authorization amount to the hospital and compelled the complainant to pay the entire amount of Rs.7,51,388/-and denied/repudiated his medical claim without any reasonable cause and excuse vide their denial letter No.80591515-01 dated 15.10.2021 with remarks that "Non Disclosure Of Material Facts At The Time Of Proposal CVA 2020 Prior Policy And Non Disclosure Of Material Facts/Pre-Existing Ailments At The Time of Proposal". It was next pleaded that several requests were made to the opposite parties by the complainant even through E-mail for the release of the medical claim amount and during conversation of complainant and opposite parties via E-mails, complainant gave every answer to the query of the opposite parties alongwith proof (MRI report of CVA) but the opposite parties refused to admit the claim of the complainant and ultimately terminated the policy in question of the complainant vide letter dated 06.11.2021. Complainant further alleged that opposite parties in order to avoid themselves from paying the medical claim amount to him repudiated his medical claim without any reason and reasons stated by the opposite parties to repudiate the claim carries no relevancy because at the time of issuing the medical policy he was proper checked up by the doctors on the empanelment of the opposite parties and it was clearly mentioned in the Policy Cover Note by the opposite parties that complainant has no pre-existing disease and as such the act of the opposite parties to withheld the medical claim amount is illegal, null & void and against the rules and regulations, hence this complaint.

3.       Upon notice opposite parties appeared through their counsel and filed their written reply by taking the preliminary objections that

complainant has no cause of action and locus standi to the file the present complaint and insurance is contract between the two parties and both the parties bind with the policy and its terms and conditions and contract of insurance is based upon utmost good faith and the insured breached the said good faith and concealed the material facts regarding health at the time of getting policy. It is further pleaded that  there is no deficiency on the part of the Insurance Company. It is further pleaded that claim of the complainant was repudiated by the opposite parties on the ground that the complainant kept concealed about his health prior to the issuance of the policy under plan namely "Care Floater" bearing policy No.30013982 providing policy coverage to the complainant and his wife Mrs.Reena which was started from 05.02.2021 to 04.02.2023 for a sum insured upto Rs.7,00,000/- subject to the policy terms and conditions. (Many observations, clauses, IRDAI regulations and judgments are mentioned by the opposite parties in para No.5 of preliminary objections which may be read as part of written reply). It is further pleaded that if this Ld. Commission comes to the conclusion that there is any liability of Insurance Company then in that case it is as per coverage under the policy and after making the compulsory deduction. On merits, it was stated that complainant at his own obtained policy No.30013982, Plan:- CARE, Cover Type:- Floater, Policy period start date 00.00 hrs 05.02.2021 till midnight 04.02.2023 and paid Rs.44,568/- as single mode premium in good faith based on the representations and disclosures made by him in the proposal form and his wife namely Reena is the nominee of the policy in which cashless facility was provided to him.  It is further pleaded that complainant did not disclose the material facts to the opposite parties at the time of getting the policy regarding their health and by concealment obtained the same. It was admitted that an amount of Rs.1,42,031/- was sanctioned by the opposite parties vide claim No.80578659 dated 25.09.2021 as per terms and conditions of policy. It is further pleaded that on 08.10.2021 complainant got admitted at Max Saket, New Delhi due to disease (Right FTP Subacute On Chronic SDH Status Post Right FTP Minicraniotomy) and remained admitted till 15.10.2021 and prior information was duly made to the opposite parties and pre-authorization amount of Rs.4,87,969/- was sanctioned to the hospital authorities at the time of admission. It is further pleaded that after pre-authorization opposite parties came to know about the pre-existing ailment of the insurer/complainant and denied his claim vide denial letter dated 15.10.2021 with the remarks that "Non Disclosure Of Material Facts At The Time Of Proposal CVA 2020 Prior Policy And Non Disclosure Of Material Facts/Pre-Existing Ailments At The Time of Proposal" and "the cashless hospitalization could not be approved as per terms and condition of the policy" and as such opposite parties had rightly repudiated the claim of the complainant. It is further pleaded that complainant intentionally and deliberately concealed the material facts regarding his pre-existing ailments of his health and as such he is not entitled for any claim from the opposite parties. All other averments made in the complaint have been denied and prayed for dismissal of the complaint.

4.       Counsel for the complainant to prove the case had filed affidavit of complainant Ex.CW-1/A with copies of documents Ex.C1 to Ex.C12.

5.       On the other hand counsel for the opposite parties had filed affidavit of Parth Arora authorized signatory Ex.OPW-1/A with copies of documents Ex.OP-1 to Ex.OP-6.

6.       Rejoinder on behalf of complainant filed.

7.       Written arguments filed by the complainant but not filed by the opposite parties.

8.       Counsel for the complainant has argued that during the continuation of health policy of insurance the complainant remained admitted at Fortis Hospital Amaritsar for his treatment from 19.09.2021 to 25.09.2021 and medical claim of the complainant to the tune of Rs.1,42,031/- was sanctioned by the opposite parties. It is further argued that at the time of discharge certain objections were raised by the opposite parties before releasing medical claim vide deficiency letter dated 25.09.2021 and in reply to said letter Fortis Hospital Amrtisar had sent requisites information to the opposite parties and amount was paid by the opposite parties. It is further argued that on 08.10.2021 complainant again remained admitted at Max Saket, New Delhi due to disease (Right FTP Subacute On Chronic SDH Status Post Right FTP Minicraniotomy) and amount of Rs.7,51,388/-  was paid by the complainant during his treatment. Prior intimation was given to the opposite parties and the opposite parties sanctioned pre-authorization amount of Rs.4,87,969/- to the hospital authorities but at the time of discharge opposite parties denied to even pay the pre-authorization amount to the hospital authorities and complainant was compelled to pay the entire amount of Rs. 7,51,388/-  to the hospital. Opposite parties denied medical claim vide letter dated 15.10.2021 with remarks that "Non Disclosure Of Material Facts At The Time Of Proposal CVA 2020 Prior to Policy And Non Disclosure Of Material Facts/Pre-Existing Ailments At The Time of Proposal" and act of opposite parties amounts to deficiency in service on their part.

9.       Counsel for the opposite parties has argued that the claim was repudiated as the complainant concealed his health status prior to the issuance of the policy. It is further argued that as per discharge summary complainant was diagnosed with Right FTP Subacute On Chronic SDH Status Post Right FTP Minicraniotomy and urinary tract infection (Enetrococcus Faecium) Aki on Chronic Kidney Disease Diabetes Mellitus Hypertension and on perusal of said document complainant was found to known case of ischemic stroke August 2020 with left hemiparesis, diabetes mellitus, hypertension, CKD, bilateral DJ stenting done on 23.09.2021. Accordingly claim was rightly rejected by the opposite parties under clause 7.1 and as such complaint is liable to be dismissed.

10.     We have heard the counsels for the parties and gone through the record. It is admitted fact that complainant purchased a health insurance policy from the opposite parties which was valid from 05.02.2021 to 04.02.2023. It is further admitted fact that on 19.09.2021 to 25.09.2021 complainant remained under treatment at Fortis Hospital Amritsar and medical claim to the tune of Rs.1,42,031/- was sanctioned and paid by the opposite parties. It is further admitted fact that deficiency letter dated 25.09.2021 was issued by the opposite parties which was replied by the Fortis Hospital Amritsar and the opposite parties had thereafter released the amount of Rs.1,42,031/-. It is further admitted fact that complainant again remained admitted at Max Saket, New Delhi w.e.f. 08.10.2021 to 15.10.2021 for deceased Right FTP Subacute On Chronic SDH Status Post Right FTP and amount of Rs.7,51,388/- was spent by the complainant. It is further admitted fact that opposite parties sanctioned pre-authorization amount of Rs.4,87,969/- to the hospital authorities and thereafter declined the same. It is further admitted fact that medical claim of the complainant was denied vide letter dated 15.10.2021 with the remarks that non disclosure of material facts at the time of proposal CVA 2020 prior and non disclosure of pre-existing ailments in the proposal. The only disputed point for adjudication before this Commission is that whether the denial of claim by the opposite parties on account of non-disclosure of material facts amounts to deficiency in service or not.

11.     To prove his case complainant has placed on record copy of policy of insurance Ex.C1, copy of cashless authorization letter Ex.C2, copy of deficiency letter Ex.C3, copy of second cashless authorization letter Ex.C4, copy of cashless authorization letter dated 09.10.2021 Ex.C5, copy of denial letter Ex.C6, copy of notice for cancellation Ex.C7, copy of E-mail correspondence Ex.C8, copy of medical treatment record and bills Ex.C9 to Ex.C12 whereas opposite parties have placed on record copy of welcome letter Ex.OP-1, pre-authorization form for cashless hospitalization Ex.OP-2, copy of discharge summary Ex.OP-3, copy of denial letter dated 15.10.2021 Ex.OP-4, copy of discharge summary of Max Hospital Ex.OP-5, claim denial letter Ex.OP-6. The main ground for denial of claim by the opposite parties is Ex.OP-3 discharge summary as per which in the column of history ischemic stroke August 2020 with left hemiparesis, diabetes mellitus, hypertension, CKD, bilateral DJ stenting done on 23.09.2021 has been mentioned but we are of the view that the policy of insurance inception date is 05.02.2021 but stenting was done on 23.9.2021 and there is no medical record  or evidence in the shape of medical history, treatment record or affidavit of treating doctor that complainant suffered stroke in the year 2020. As such we are of the view that denial of the claim by the opposite parties on the ground of concealment of pre-existing disease prior to the policy inception is totally unjustified. It is also noticed that vide E-mail dated 16.11.2021 complainant has clarified the wrong mentioning of the year 2020 but opposite parties were bent upon denying the claim. Even the opposite party has not proved on record as to what is the nexus between the both the diseases.

12.     Accordingly, complainant has fully proved the deficiency in service on the part of the opposite parties and as such complaint is partly allowed and opposite parties are directed to pay the amount of Rs.4,87,969/- regarding which pre-authorization was given alongwith interest @ 9% P.A. from the date of denial i.e. 15.10.2021 till realization. It is further held that since the denial of the claim was totally unjustified and unreasonable as such termination of policy vide letter dated 06.11.2021 is also set aside and opposite parties are further directed to revive the health policy of insurance of the complainant. Entire exercise will be completed within 30 days from the date of receipt of copy of this order.         

13.      The complaint could not be decided within the stipulated period due to heavy pendency of Court Cases.

14.     Copy of the order be communicated to the parties free of charges. After compliance, file be consigned to record room. 

                               (Lalit Mohan Dogra)

                                                                       President   

Announced:                                          (B.S.Matharu)

Oct. 12, 2023                                                Member

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